INTRODUCTION
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a bariatric procedure with a typical length of stay of two days. (1, 2) With the promotion of fast-track and Enhanced Recovery After Surgery (ERAS) protocols, there have been increasing reports of successful patient discharge on postoperative day 1 (POD1) after LRYGB. (1–14)
In some institutional series, the successful rate of POD1 discharge in select patients after LRYGB is >80%, with rates of 30-day complications and readmission around 2%. (8) On a national level, Morton et al (1) used the Bariatric Outcomes Longitudinal Database to compare 9,513 patients discharged POD1 with 30,592 patients discharged postoperative day 2 after LRYGB and found no difference in risk-adjusted 30-day mortality, serious complications, or readmissions. Khorgami et al (14) used the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to compare outcomes between 2,960 patients who were discharged on POD1 versus 13,523 patients who were discharged on postoperative day 2–3 after LRYGB, and found that patients discharged on POD1 had fewer complications than patients discharged later (2.6% versus 4.1%, respectively; P < 0.001). These studies further support that POD1 discharge after LRYGB is well tolerated.
Given the apparent trend toward shorter hospitalization and the increasing evidence for successful POD1 discharge after LRYGB, the next step is to examine the feasibility of same-day discharge after LRYGB. However, there are currently no studies that compare outcomes between same-day and POD1 discharge after LRYGB, likely because the novel practice of same-day discharge after LRYGB is currently limited to ≤1.0% of cases. (1, 2) Therefore, the aim of the current study was to evaluate the outcomes of patients with same-day versus POD1 discharge after LRYGB using the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.
METHODS
Database
The MBSAQIP database is the largest bariatric-specific registry in the United States. The 2015 participant user file is the first MBSAQIP database available for analysis, and contains Health Insurance Portability and Accountability Act (HIPAA)-compliant patient-level data on over 150,000 metabolic and bariatric cases performed between January 1-December 31, 2015 across 742 centers in the United States and Canada.
Patient Population
The 2015 MBSAQIP database was analyzed for patients aged 18 years or older who underwent elective LRYGB on the day of admission with either same-day or POD1 discharge. To reduce possible confounding variables, only conventional laparoscopic procedures were included. Laparoscopic-assisted, hand-assisted, single-incision, natural-orifice, robotic-assisted, and open procedures were excluded. Patients with American Society of Anesthesiologists (ASA) class V or higher were excluded. Patients were also excluded if they had a history of prior bariatric or foregut surgery or were undergoing revisional surgery.
Outcome Measures
Primary outcome measures included 30-day mortality and overall morbidity. Only mortality events that were identified in the database as being related to the index operation were included in the analysis. Secondary outcome measures included 30-day readmission and reoperation. Only cases of readmission and reoperation that were identified in the database as being both unplanned and related to the index operation were included in the analysis.
Statistical Analysis
The statistical program SAS version 9.4 (SAS Institute, Cary, NC) was used for analysis. For continuous variables, t-tests were used to compare the means of between the two groups. For categorical variables, Fisher exact tests (due to small numbers in some categories) were used to compare the proportions between the two groups. Multivariate logistic regression was used to determine risk-adjusted outcomes for same-day versus POD1 discharge. Risk adjustments included patient demographic and clinical characteristics with P < 0.1 based on univariate analysis. Patients with missing preoperative variables were excluded from the regression analysis. Two-sided tests with P < 0.05 were considered statistically significant. Bonferroni correction was used to adjust the P values for multiple comparisons.
RESULTS
There were 39,515 conventional LRYGB cases in the database, including 354 (0.9%) same-day discharges, 10,324 (26.1%) POD1 discharges, and 20,875 (52.8%) POD2 discharges. After application of inclusion and exclusion criteria, a total of 9,721 cases were analyzed, including 319 same-day and 9,402 POD1 discharges.
Patient demographics and clinical characteristics are summarized in Table 1. On univariate analysis, statistically significant differences between same-day versus POD1 discharge included higher mean body mass index (BMI) (47.3 versus 45.9 kg/m2, respectively; P = 0.0024), racial distribution, and higher percentage of patients with Hispanic ethnicity (11.9% vs. 12.0%, respectively; P = 0.0079). There were no statistically significant differences between the two groups for other evaluated characteristics or comorbidities.
Table 1.
Patient Demographics and Clinical Characteristics for Same-Day Versus First-Postoperative-Day (POD1) Discharge After Laparoscopic Roux-en-Y Gastric Bypass
| Characteristic | Same-day (n = 319) | POD1 (n = 9,402) | p Value |
|---|---|---|---|
| Age, y, mean (SD) | 45.0 (12.0) | 44.5 (11.8) | 0.5022 |
| Age, y, median (IQR) | 44.0 (36–54) | 44.0 (36.0–53.0) | |
| BMI, kg/m2, mean (SD) | 47.3 (7.5) | 45.9 (8.0) | 0.0024 |
| BMI, kg/m2, median (IQR) | 46.6 (41.8–52.0) | 44.6 (40.3–50.0) | |
| Female, n (%) | 256 (80.3) | 7,262 (77.2) | 0.2212 |
| Race, n (%) | |||
| White | 229 (71.8) | 7,480 (79.6) | 0.0031 |
| Black or African American | 63 (19.8) | 1,143 (12.2) | |
| Asian | 2 (0.63) | 49 (0.52) | |
| Other | 3 (0.94) | 95 (1.01) | |
| Unknown/not reported | 22 (6.90) | 635 (6.75) | |
| Hispanic ethnicity, n (%) | 38 (11.9) | 1,129 (12.0) | 0.0079 |
| ASA Class, n (%) | |||
| I | 1 (0.31) | 14 (0.15) | 0.3634 |
| II | 45 (14.1) | 1,568 (16.7) | |
| III | 257 (80.6) | 7,397 (78.7) | |
| IV | 16 (5.02) | 423 (4.50) | |
| Comorbidity, n (%) | |||
| Hypertension | 164 (51.4) | 4,785 (50.9) | 0.8645 |
| Diabetes | 110 (34.5) | 3,074 (32.7) | 0.5050 |
| Hyperlipidemia | 103 (32.3) | 2,629 (28.0) | 0.0995 |
| COPD | 7 (2.19) | 159 (1.69) | 0.5040 |
| Sleep apnea | 133 (41.7) | 3,604 (38.3) | 0.2418 |
| History of myocardial infarction | 5 (1.57) | 119 (1.27) | 0.6063 |
| History of PCI | 4 (1.25) | 193 (2.05) | 0.4194 |
| History of cardiac surgery | 3 (0.94) | 84 (0.89) | 0.7632 |
| Renal insufficiency | 1 (0.31) | 40 (0.43) | 0.9999 |
| Renal failure | 0 (0.00) | 9 (0.10) | 0.9999 |
| Venous stasis | 3 (0.94) | 122 (1.30) | 0.8004 |
| History of DVT | 5 (1.57) | 141 (1.50) | 0.8146 |
| History of PE | 3 (0.94) | 74 (0.79) | 0.7413 |
| Chronic steroid use | 2 (0.63) | 108 (1.15) | 0.5884 |
| Smoker | 36 (11.3) | 772 (8.21) | 0.0624 |
| Functional status, n (%) | |||
| Independent | 316 (99.1) | 9,327 (99.2) | 0.6591 |
| Partially dependent | 3 (0.94) | 62 (0.66) | |
| Totally dependent | 0 (0.00) | 13 (0.14) |
Values are reported as frequencies (%) unless otherwise indicated.
ASA, American Society of Anesthesiologists; BMI, body mass index; COPD, chronic obstructive pulmonary disorder; DVT, deep vein thrombosis; IQR, interquartile range; PCI, percutaneous coronary intervention; PE, pulmonary embolus; POD, postoperative day
Perioperative characteristics are listed in Table 2. On univariate analysis, there was no statistically significant difference between the two groups for operative time. Statistically significant differences between same-day versus POD1 discharge included distribution of the first-assistant training level and use of routine or selective postoperative swallow study.
Table 2.
Perioperative Characteristics for Same-Day Versus First-Postoperative-Day Discharge (POD1) After Laparoscopic Roux-en-Y Gastric Bypass
| Characteristic | Same-day (n = 319) | POD1 (n = 9,402) | p Value |
|---|---|---|---|
| Operative time, min, mean (SD) | 107.4 (52.9) | 104.4 (46.2) | 0.3253 |
| Operative time, min, median (IQR) | 95 (72–127) | 96 (73–126) | |
| First assistant, n (%) | |||
| PA/NP | 107 (33.5) | 3,649 (38.8) | 0.0002 |
| Resident | 39 (12.2) | 1,410 (15.0) | |
| Fellow | 29 (9.09) | 1,252 (13.3) | |
| Attending | 79 (24.8) | 1,817 (19.3) | |
| None | 65 (20.4) | 1,274 (13.6) | |
| Swallow study, n (%) | |||
| Routine | 82 (25.7) | 1,800 (19.1) | 0.0145 |
| Selective | 2 (0.63) | 85 (0.90) | |
| None | 235 (73.7) | 7,517 (80.0) |
Values are reported as frequencies (%) unless otherwise indicated
NP, nurse practitioner; NS, not significant; PA, physician assistant; POD, postoperative day; SD, standard deviation
Postoperative outcomes are summarized in Table 3. On univariate analysis, there was a statistically significant higher rate of mortality for same-day versus POD1 discharge (0.94% versus 0.05%, respectively; P = 0.0017). Reasons for mortality in the same-day discharge group included hemorrhage (N = 1), other respiratory failure (N = 1), and unlisted (N = 1). Reasons for mortality in the POD1 discharge group included intestinal obstruction (N = 1), vein thrombosis requiring therapy (N = 2), and unlisted (N = 2). Compared to POD1 discharge, same-day discharge had higher overall morbidity (3.76% versus 1.54%, respectively; P = 0.0055), higher rates of cardiac arrest requiring cardiopulmonary resuscitation (0.63% versus 0.01%, respectively; P = 0.0032), higher rates of unplanned intubation (0.94% versus 0.06%, respectively; P = 0.0025), higher rates of unplanned admission to the intensive care unit (1.25% versus 0.29%, respectively; P = 0.0178), and higher rates of renal insufficiency/failure (0.94% versus 0.09%, respectively; P = 0.0047). There were no statistically significant differences between same-day versus POD1 discharge for rates of readmission (3.45% versus 3.66%, respectively; P = 0.7699) or reoperation (1.88% versus 0.89%, respectively; P = 0.1273).
Table 3.
Thirty-Day Outcomes for Same-Day Versus First-Postoperative-Day (POD1) Discharge After Laparoscopic Roux-en-Y Gastric Bypass
| Outcome | Same-day (n = 319) |
POD1 (n = 9,402) |
p Value | ||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Mortality | 3 | 0.94 | 5 | 0.05 | 0.0017 |
| Overall morbidity | 12 | 3.76 | 145 | 1.54 | 0.0055 |
| Surgical site infection | 4 | 1.25 | 71 | 0.76 | 0.3128 |
| Superficial | 3 | 0.94 | 56 | 0.60 | 0.4445 |
| Deep | 0 | 0.00 | 4 | 0.04 | 0.9999 |
| Organ space | 1 | 0.31 | 11 | 0.12 | 0.3301 |
| Urinary tract infection | 1 | 0.31 | 21 | 0.22 | 0.5204 |
| Cardiac arrest requiring CPR | 2 | 0.63 | 1 | 0.01 | 0.0032 |
| Myocardial infarction | 1 | 0.31 | 3 | 0.03 | 0.1250 |
| Postoperative ventilator | 0 | 0.00 | 3 | 0.03 | – |
| Unplanned intubation | 3 | 0.94 | 6 | 0.06 | 0.0025 |
| Unplanned ICU admission | 4 | 1.25 | 27 | 0.29 | 0.0178 |
| Pneumonia | 0 | 0.00 | 12 | 0.13 | 0.9999 |
| Deep vein thrombosis | 0 | 0.00 | 12 | 0.13 | 0.9999 |
| Pulmonary embolism | 1 | 0.31 | 10 | 0.11 | 0.3073 |
| Renal insufficiency/failure | 3 | 0.94 | 8 | 0.09 | 0.0047 |
| Sepsis | 1 | 0.31 | 4 | 0.04 | 0.1537 |
| Septic shock | 0 | 0.00 | 3 | 0.03 | 0.9999 |
| Readmission | 11 | 3.45 | 344 | 3.66 | 0.7699 |
| Reoperation | 6 | 1.88 | 84 | 0.89 | 0.1273 |
POD, postoperative day.
Values are reported as frequencies (%) unless otherwise indicated.
CPR, cardiopulmonary resuscitation; ICU, intensive care unit; UTI, urinary tract infection
Table 4 lists results of the multivariate logistic regression analysis comparing outcomes between same-day versus POD1 discharge. Risk-adjusted mortality was not performed because it did not fit into the regression model due to the low number of events. Patients with same-day discharge had higher risk-adjusted odds of overall morbidity compared to patients with POD1 discharge (adjusted odds ratio [AOR] 2.41, P = 0.0216). There were no significant differences between the same-day versus POD1 discharge groups for risk-adjusted readmissions (AOR 0.85; P = 0.9999), or reoperations (AOR 2.33; P = 0.2428). Additional adjustments were made for assistant training level and postoperative swallow study, since these variables were found to be statistically different between the two groups on univariate analysis. The secondary multivariate regression analysis was similar to the original analysis, with higher risk-adjusted overall morbidity in the same-day versus POD1 discharge group (AOR 2.55; P = 0.0126), and no statistically significant difference in risk-adjusted rates of readmission or reoperation.
Table 4.
Risk-Adjusted 30-Day Outcomes for Same-Day Versus First-Postoperative-Day (Reference) Discharge After Laparoscopic Roux-en-Y Gastric Bypass
| Outcome | AOR∗ (95% CI) | p Value | AOR† (95% CI) | p Value |
|---|---|---|---|---|
| Overall morbidity | 2.41 (1.32–4.41) | 0.0216 | 2.55 (1.39–4.69) | 0.0126 |
| Readmission | 0.85 (0.46–1.56) | 0.9999 | 0.86 (0.63–2.15) | 0.9999 |
| Reoperation | 2.33 (0.01–5.26) | 0.2428 | 2.38 (0.18–0.97) | 0.2091 |
AOR, adjusted odds ratio.
Adjusted for body mass index, race, Hispanic ethnicity, hyperlipidemia, smoker
Additional adjustment for the level of first assistant and performance of a swallow study
AOR, adjusted odds ratio; CI, confidence interval
DISCUSSION
Based on a large, national bariatric surgery database, the current study showed that same-day discharge after LRYGB is limited in practice, occurring in <1% of patients undergoing conventional LRYGB. However, a significant percentage of patients are being discharged on POD1 after surgery (27%). Compared to POD1 discharge, same-day discharge was associated with higher rates of mortality and risk-adjusted overall morbidity. There was no statistically significant difference for risk-adjusted odds of readmission or reoperation between the two groups.
In this study, a risk-adjusted analysis for mortality could not be performed due to the rarity of events, only three deaths occurring in the same-day discharge group and five deaths occurring in the POD1 discharge group. Based on univariate analysis, mortality was significantly higher for same-day versus POD1 discharge (0.94% versus 0.05%; P = 0.0017). In a study of 51,788 LRYGB cases using the Bariatric Outcomes Longitudinal Database, Morton et al (1) compared 507 same-day discharge cases with 30,592 cases discharged after a two-day length of stay and similarly found that same-day discharge was associated with higher risk-adjusted odds of 30-day mortality (0.8% versus 0.1%, respectively; AOR 12.97; P < 0.0001).
We hypothesize that the increased mortality after same-day discharge may due to failure to rescue when patients developed respiratory or other complications at home in an unmonitored and unsupervised setting. It is important to note that over 40% of patients in the same-day discharge group had a diagnosis of sleep apnea, particularly given the high risk for postoperative respiratory depression in this group of patients after anesthesia combined with postoperative narcotic usage. While there are a number of studies demonstrating safe POD1 discharge after LRYGB in the context of Enhanced Recovery After Surgery protocols, it is unknown which patient characteristics and comorbidities would allow for safe same-day discharge after LRYGB. (2–14) Studies on successful same-day discharge after laparoscopic sleeve gastrectomy excluded patients with sleep apnea or cardiac disease, suggesting that same-day discharge after bariatric surgery may be safe in select patients. (15–17) However, in the current study, same-day discharge was associated with higher rates of unplanned postoperative intubation compared to the POD1 discharge, as well as statistically higher rates of cardiac arrest and unplanned admission to the intensive care unit. It is likely that poor patient selection for same-day discharge to an unmonitored setting resulted in higher rates of respiratory and cardiac complications, which in turn may have contributed to the higher mortality observed in the same-day discharge group.
There are several limitations to this study. First, this study is subject to the inherent biases of all retrospective database studies, including possible selection bias and bias from inaccurately recorded or missing data. Additionally, since the comparison groups were determined retrospectively based on day of discharge, there may be additional bias from patients who were intended for same-day discharge but were instead discharged at a later date due to the clinical need for continued hospitalization. Furthermore, the MBSAQIP does not include variables on specific centers or surgeons, thus the results could not be adjusted for these factors. This is important to note, as bariatric surgery performed at high-volume centers or by high-volume surgeons is associated with improved outcomes. (18–20) Finally, the data in this study were collected from Bariatric Centers of Excellence accredited by the MBSAQIP, and results may not be representative of non-accredited institutions.
CONCLUSION
While previous studies have demonstrated that POD1 discharge after LRYGB in carefully selected patients is feasible with good outcomes, particularly in the context of Enhanced Recovery After Surgery (ERAS) protocols, same-day discharge after LRYGB is associated with significantly higher morbidity and mortality compared POD1 discharge. Despite the trend toward shorter postoperative hospital stays, same-day discharge after LRYGB should be considered experimental until further research determines the optimal patient for safe accelerated discharge.
Acknowledgments
FUNDING
The statistical analysis for this study was partially supported by grant UL1 TR001414 from the National Center for Advancing Translational Sciences, National Institutes of Health (NIH), through the Biostatistics, Epidemiology and Research Design Unit at the University of California Irvine. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The NIH had no role in the study design; the collection, analysis, or interpretation of data; the writing of the report; or the decision to submit the report for publication.
ABBREVIATIONS
- AOR
adjusted odds ratio
- ASA
American Society of Anesthesiologists
- BMI
body mass index
- HIPAA
Health Information Portability and Accountability Act
- LRYGB
laparoscopic Roux-en-Y gastric bypass
- MBSAQIP
Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
- POD
postoperative day
Footnotes
DISCLOSURES
The American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and the centers participating in the ACS MBSAQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
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